Capitol Spine & Rehabilitation/ Disc Center of America - Baton Rouge
Intake Forms
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Capitol Spine & Rehabilitation/ Disc Centers of America - Baton Rouge
Medical History Form
Name
First Name
Last Name
Age
Height
Weight
Please select any of the following conditions that may apply to your medical history:
Frequent Colds
Frequent Headaches
Allergies
Measles
Mumps
Chickenpox
HIV/AIDS
Anemia
Blood Disorder
Anxiety
Mental Depression
Heart Condition
High Blood Pressure
Chest Pain
Stroke
Epilepsy
Dizziness
Cancer
Neck and Back Pain
Shoulder, Elbow, Wrist, Hand/ Hip, Knee, Ankle, Foot Joint Pain
Arthritis
Hepatitis
Diabetes
Kidney Condition
GI Condition
Ulcers
Acid Reflux
Lung Condition
Tuberculosis
Difficulty Breathing
Asthma
Hearing Condition
Serious Injury
Please give details/explain any of the conditions checked above:
Have you been in an auto accident within the last five years?
Yes
No
Are you currently taking any medications? If yes, please list
Have you had any inpatient/outpatient surgeries? If yes, please describe
Have you recently been tested for HIV?
Yes
No
Are you allergic to any medications? If yes, please list.
Are you currently pregnant?
Yes
No
Have you had a x-ray or MRI within the last 12 months?
Yes
No
On a scale from 1 - 10, 1 being able to do whatever you want with no limitations, and 10 being, I can barely get out of bed; how do you feel?
1-2 (light limitations)
3-4 (mild limitations)
5-6 (moderate limitations)
7-8 (severe limitations)
9-10 (barely get out of bed)
No limitations (I feel great!)
Do you have trouble with sleeping?
Yes
No
If so how often?
Daily
Occasionally
Socially
Rarely
Never
Formerly
Do you have trouble with standing?
Yes
No
If so how often?
Daily
Occasionally
Socially
Rarely
Never
Formerly
Do you have trouble with sitting?
Yes
No
If so how often?
Daily
Occasionally
Socially
Rarely
Never
Formerly
Do you feel like your pain is getting worse?
Yes
No
How long have you been dealing with your pain?
Days
Weeks
Months
Years
Formerly (no more pain)
If your pain is getting worse: What do you think the next 5 years are going to look like if you do not get your pain fixed?
Poor (Hurting daily)
Fair (Hurting frequently)
Good (Hurting occasionally)
Great (Hurting rarely)
Formerly (no more pain)
Up until today... What is everything you have done to treat your pain?
Taking medication(s)
Shot(s)/ injection(s)
Surgery(s)
If any, how has your previous treatment been working?
Poor (Hurting daily)
Fair (Hurting frequently)
Good (Hurting occasionally)
Great (Hurting rarely)
Formerly (no more pain)
Do you work for a living?
Yes
No
How often does your pain affect you at work?
Daily
Frequently
Occasionally
Rarely
Never
Formerly (no more pain)
After everything you have shared, we are interested in knowing - If you were completely free of pain, how would you spend your day?
Relax and Rejuvenate (Listen to Music/ Read a Book)
Catch up with Family and Friends
Work on a Project/ Plan Your Week
Learn Something New
Volunteer
Enjoy Day in City/Town (Explore Shops, Restaurants, and/or Cafes)
Attend an Event(s) (Listing(s) in the Area)
Take a Day Trip (Explore nearby Towns or Attractions)
Go to the Gym or Exercise
Spend Time on Hobbies
Do you smoke?
Yes
No
If so, how often?
Daily
Occasionally
Socially
Rarely
Never
Formerly
Do you drink Alcohol?
Yes
No
If so, how often?
Daily
Occasionally
Socially
Rarely
Never
Formerly
Have you ever abused prescription/illegal drugs?
Yes
No
If so, how often?
Daily
Occasionally
Socially
Rarely
Never
Formerly
Are you single or married?
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Do you have any children?
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If yes, how many?
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What is your occupation?
Are you a student?
Signature
Date: Signed
Parent or guardian/ relationship to patient
Submit
Submit
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